My patient and his wife didn't understand that an anesthesiologist is a physician, despite his having been cared for by anesthesiologists during past procedures. They thought only CRNAs give anesthesia. What are we doing so wrong with our messaging, and how can we fix it?
One recent afternoon in the GI endoscopy suite (not my favorite place to work, but that's a topic for another day), I walked up to the bedside of my next patient and introduced myself as I always do.
“Hi,” I said, holding up my name badge for the patient and his wife to see. “I'm Dr. Sibert. I'm with the anesthesiology department and I'll be looking after you today.”
The patient was an otherwise healthy man in his mid-30s, having his fifth endoscopy this year for a chronic though serious problem. My questions were few and he understood very well what was about to happen.
The consent process concluded, and I asked if the couple had any other questions. The wife did.
“You're a doctor when you're not giving anesthesia?” she asked.
I'm seldom speechless, but this question took me by surprise. “Why, yes,” I said, unsure how to respond.
“You're a doctor, and you give anesthesia,” the patient's wife said, making sure she heard correctly. “Usually we've had CRNAs.”
“Yes,” I said. “I'm a doctor, and I give anesthesia all the time. I'm actually an MD who specializes in anesthesiology.”
The patient's wife seemed slightly embarrassed but happy to acquire this new (to her) information – that doctors give anesthesia too, and that anesthesiology is a specialty practiced by physicians.
“So it must take a lot more training,” she mused. I confirmed that was true and outlined the years of medical school, residency, and often fellowship training that we undertake to become fully qualified.
Since the patient and his wife seemed interested, I explained that there's more to anesthesiology than the brief sedations he had experienced in the GI suite. I explained a little about my own specialty – thoracic anesthesia – and the challenge of ventilating each lung separately for lung operations. I went on to mention some of the other subspecialties, including pediatric and cardiac anesthesiology.
At the mention of cardiac anesthesiology, a light bulb seemed to go off in the patient's mind. “I think I had a cardiac anesthesiologist one time,” he said.
At that point, the GI team was ready to begin his procedure, so there was no more time to chat. I gave the patient's wife my business card with my title: Clinical Professor of Anesthesiology and Perioperative Medicine. We headed to the procedure room. The circulating nurse and I hooked up his monitors; I started the propofol infusion. I watched his breathing and vital signs until the endoscopy was completed, turned the propofol off, and watched him wake up.
So many questions
This brief encounter left me with so many unanswered questions, and the unhappy feeling that no matter how much we may have done to try to explain the profession of anesthesiology to the lay public, clearly we're not getting through.
This patient and his wife were not uneducated or economically disadvantaged. This was not their first encounter with the health care system; he had undergone four prior procedures at our teaching hospitals this year. If he received care from nurse anesthetists, they would have been under the medical direction of anesthesiologists. California is an opt-out state, but our health system does not permit nurse anesthetists to practice unsupervised.
How could the patient and his wife believe that all his prior anesthetic care had been given by nurse anesthetists?
My first hypothesis was that perhaps the patient had been taken care of by a mix of female anesthesiologists and female nurse anesthetists, all wearing the same nauseatingly pale green scrubs. It could be hard to tell one person from another – let alone remember who's who – in the fast-moving assembly line of an outpatient GI endoscopy suite.
But when I looked up the patient's previous records, that wasn't the case at all. Here's the roster of anesthesia personnel for his four prior procedures, in chronologic order from first to most recent:
Female anesthesiologist and male nurse anesthetist
Male anesthesiologist, solo
Male anesthesiologist and male nurse anesthetist
Female anesthesiologist, solo
It turned out that the male anesthesiologist who worked solo was indeed a cardiac anesthesiologist, exactly as the patient recalled after our conversation jogged his memory.
So the total number of anesthesiologists who cared for this patient before I did was four – two women and two men – and the total number of nurse anesthetists was two, both men. Yet the impression he and his wife retained was that CRNAs gave him anesthesia. What can we make of that?
I'm sympathetic to the kindly impulse that can lead some of us to introduce ourselves by first names instead of using the title “Doctor.” We don't want to seem elitist in the eyes of patients or staff. But is this a good idea?
There is evidence that reduction of “hierarchy” can improve patient safety by making it feel less threatening for anyone junior – whether in terms of age, professional rank, experience, or education – to question what is happening or about to happen. That's the theory behind programs such as “Team Strategies and Tools to Enhance Performance and Patient Safety (TeamSTEPPS®).” Timothy Clapper, PhD, writing about the experience with TeamSTEPPS at Weill Cornell Medical College, states: “Healthcare workers may not speak up, even when it could make a difference for patient safety because they do not want to be wrong, are unsure, or do not want to hurt someone's feelings.”
However, Dr. Clapper also notes: “From a communication standpoint, hierarchies are beneficial for healthcare teams, especially when time and clarity is an issue. Team members prefer to have a clear leader on their team. An effective leader operating in a suitable level of the hierarchy can quickly assign tasks and roles, especially during emergent cases to ensure task coverage and minimize delays. In healthcare systems, physicians regularly take on leadership roles and decision-making responsibilities.”
For physicians to assume those leadership roles, the key is for each person in the room to understand who is a physician and who is not.
If everyone on the team is introduced on a first-name basis, it may not be clear at all who is who and which personnel are in leadership positions. This may be especially true when some people on the team are youthful trainees who rotate on and off teams in the course of their training. Is “Annabelle” an attending physician, a resident, a nurse, a nurse anesthetist, a physician assistant, a medical student, or a technician? Confusion is almost inevitable when you can't tell the players without a scorecard, and confusion can be lethal in a crisis.
First and last names??
Even when both first and last names are used, without the title “Doctor” in front of the name, a listener may not appreciate that the speaker is a physician.
The Editor-in-Chief of the ASA Monitor, Steven Shafer, MD, wrote a column in the August 2021 issue, explaining that he introduces himself to patients by saying, “Hello, I'm Steve Shafer. I'm the anesthesiologist who will be caring for you today.” He assumes that using the term “anesthesiologist” is sufficient to communicate the message that he is a physician with subspecialty training in anesthesiology.
This may work for many patients, but not all. A recent survey by the American Medical Association found that 70% of patients recognized an anesthesiologist as a physician, 22% did not, and 8% were unsure. Several years ago, in the interest of truth in advertising, ASA decided to champion the term “physician anesthesiologist.” Unfortunately, “physician anesthesiologist” is clumsy and difficult to say out loud without tripping over your own tongue. Does anyone use it in everyday conversation?
“Whatever the reason, I think we need to acknowledge that there is a problem. We can't have it both ways: abandoning formal titles and then complaining that no one knows we're physicians. We can't assume that our profession is going to get the respect it deserves if we're reluctant to refer to ourselves as ‘Doctor.’”
Which brings me back to my patient and his wife, and the fact that my self-introduction as “Dr. Sibert” created a moment of clarity that had been missing before.
What could have happened in the previous encounters?
Perhaps the anesthesiologists introduced themselves as Dr. Shafer does.
Perhaps the anesthesiologists who were supervising nurse anesthetists met the patient only briefly in the procedure room right before the case started, while the actual preop interviews were done by the CRNAs. This approach enables the anesthesiologist to duck into the room and quickly tick off the attestation boxes for preop assessment, assessment prior to induction, and presence at induction all at the same moment. However, in this scenario it's unlikely that the patient will remember meeting the anesthesiologist at all.
Perhaps the term “CRNA” is just easier than “anesthesiologist” to say and remember.
Perhaps nurse anesthetists are simply better at promoting their brand.
We need to acknowledge a problem
Whatever the reason, I think we need to acknowledge that there is a problem. We can't have it both ways: abandoning formal titles and then complaining that no one knows we're physicians. We can't assume that our profession is going to get the respect it deserves if we're reluctant to refer to ourselves as “Doctor.”
We can't delegate the responsibility for doing the preoperative assessment to nurse anesthetists and then wonder why patients don't know that an anesthesiologist was involved in their care.
We shouldn't downplay our critical role in the OR by introducing ourselves with our first names. Everyone on the team needs to know who the attending anesthesiologist is. This may be even more important if the attending anesthesiologist is young or female or both, and doesn't necessarily look the part of a senior physician. During the time-out in the OR, my standard response is, “I'm Dr. Sibert, with anesthesiology.”
With patients, I routinely introduce myself as “Dr. Sibert,” trying as best I can to convey a smile behind my mask. I explain if I'm supervising a nurse anesthetist or a resident, or if I'll be taking care of the patient by myself. I give out my business card liberally, making sure that my patients have a way to contact me after surgery if any issue should arise, and at the same time making it clear that I'm a board-certified physician who specializes in anesthesiology.
I have a hard time imagining Dr. Michael DeBakey in his prime ever introducing himself as “Mike,” and I won't be saying, “Hi, I'm Karen,” anytime soon either. All of us in anesthesiology have worked long years to become the physicians we are today. We need to own it, or else stop wondering why the public doesn't know who we are.